NSA Good Faith Estimate Client Signature Page

    Breakthru Counseling & Consulting, P.C.(BCC)
    Good Faith Estimate Client Signature Page



    My signature below indicates that I have received the No Surprise Act Standard
    Notice and the “Your Rights and Protections Against Surprise Medical Bills” Notice
    and that my provider, Dr. Quincy Warner, of BCC, has gone over my No Surprise
    Act Good Faith Estimate with me and any questions or concerns have been
    addressed.

    I voluntarily choose and ask that my typed name on the signature line(s) on
    this document represent my legal electronic signature.




    Or, If Applicable: